Provider Demographics
NPI:1508052747
Name:DEWENTER, TRACY A
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:A
Last Name:DEWENTER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1340 POYDRAS ST
Mailing Address - Street 2:SUITE 1640
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70112-1221
Mailing Address - Country:US
Mailing Address - Phone:504-412-1835
Mailing Address - Fax:
Practice Address - Street 1:2021 PERDIDO ST
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70112-1352
Practice Address - Country:US
Practice Address - Phone:504-568-2315
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-21
Last Update Date:2008-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA026496207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1062545Medicaid
LA4K856F669Medicare PIN
LA4K856Medicare PIN